Friday, January 18, 2013

'Grief and anxiety are not mental illnesses'

This article was published on the BBC News website on Friday, January 18th 2013 http://www.bbc.co.uk/news/health-20986796

The forthcoming edition of an American psychiatric manual will increase the number of people in the general population diagnosed with a mental illness. - but what they need is help and understanding, not labels and medication.

Many people experience a profound and long-lasting grieving process following the death of a loved one. Many soldiers returning from conflict suffer from trauma. Many of us are shy and anxious in social situations or unmotivated and pessimistic if we're unemployed or dislike our jobs.

For a few of us, our experiences of abuse or failure lead us to feel that life is not worth living. We need to recognise these human truths and we need to offer help. But we should not regard these human experiences as symptoms of a mental illness.

Psychiatric diagnoses are not only scientifically invalid, they are harmful too. The language of illness implies that the roots of such emotional distress lie in abnormalities in our brain and biology, usually known as "chemical imbalances".

This leads us to be blind to the social and psychological causes of distress.

More importantly, we tend to prescribe medical solutions - anti-depressants and anti-psychotic medication - despite significant side-effects and poor evidence of their effectiveness.

The new diagnosis of "disruptive mood dysregulation disorder" will turn childhood temper tantrums into symptoms of a mental illness

Normal grief will become "major depressive disorder", meaning people will turn to diagnosis and prescription as a response to bereavement

The criteria for "generalised anxiety disorder" will be significantly relaxed, making the worries of everyday life into targets for medical treatment

Lower diagnostic thresholds will see more diagnoses of "adult attention deficit disorder", which could lead to widespread prescription of stimulant drugs

A wide range of unfortunate human behaviours, the subject of many new year's resolutions, will become mental illnesses - excessive eating will become "binge eating disorder", and the category of "behavioural addictions" will widen significantly to include such "disorders" as "internet addiction" and "sex addiction"

Stigma of diagnosis

Standard psychiatric diagnoses are notoriously invalid - they do not correspond to meaningful clusters of symptoms in the real world, despite the obvious importance that they should. Diagnoses fail to predict the effectiveness of particular treatments and they do not map neatly onto biological processes.

In current mental-health systems, diagnosis is often seen as necessary for accessing services. However, it also sets the scene for the misuse and overuse of medical interventions such as anti-psychotic and anti-depressant drugs, which have worrying long-term side-effects.

Scientific evidence strongly suggests distressing experiences result not from "faulty brains", but from complex interactions between biological, but more importantly, social and psychological factors.

But diagnosis and the language of biological illness obscure the causal role of factors such as abuse, poverty and social deprivation. The result is often further stigma, discrimination and social exclusion.

Therapeutic approach

There are humane and effective alternatives to traditional psychiatric diagnoses.

It is relatively straightforward to generate a simple list of problems that can be reliably and validly defined. There is no reason to assume that these phenomena cluster into diagnostic categories or are the consequences of underlying illnesses.

We can then use medical and psychological science to understand how problems might have originated, and recommend therapeutic solutions.

This approach would yield all the benefits of the current diagnosis-and-treatment approach without its many inadequacies and dangers.

4 comments:

I find this article concerning, in some ways naïve, and rebellious and although the author is a Professor, undergraduate-y and irresponsible. It is also inaccurate and poorly researched in several ways. 1. It gives the example of post-traumatic stress disorder in military personnel and suggests that such diagnoses are invalid. The identification of PTSD in combat veterans has helped the military develop robust systems to identify and treat such problems before the lives of these ex-servicemen are derailed by their condition2. True there are problems with the reliability of psychiatric diagnoses across different settings and centres but sometimes these are related to the pressures on or inclusion criteria for that service. 3. “Diagnosis implies that the roots of such emotional distress lie in abnormalities in our brain and biology, usually known as "chemical imbalances"”. It would be shameful if mental health professionals thought that depression or anxiety disorders always or even often had a biological basis and even patients don’t think this. Hansson et al 2010 found that patients often gave multi-causal explanations to their depression and biological explanations were rare. The idea that diagnosis = biological causation or that diagnosis = blindness to social and psychological causes of distress is hogwash. Even Wikipedia says this4. “More importantly, we tend to prescribe medical solutions - anti-depressants and anti-psychotic medication - despite significant side-effects and poor evidence of their effectiveness”. Well if the evidence for the effectiveness of antidepressants is poor, then the evidence for the effectiveness of psychological treatments for depression is poor also. Consistently studies have shown that antidepressants and psychological therapies are equally effective, although psychological treatments having longer term effects. Also psychological therapy is prioritised over medication for the treatment of mild to moderate depression in NICE guidelines. As for antipsychotics, again if the evidence for these is poor then the evidence for psychological interventions in psychosis is worse. As for the evidence for integrative interventions, which most clinical psychologists purport to offer sometimes without being what would be considered an expert in either of the therapies they integrate, there is no robust evidence for this dog’s dinner of an approach. Side-effects of antipsychotics are a major problem though.5. Agreed, DSM is an American system, where Medicare is dominant and influential and it probably does label some states and conditions in an inappropriate way but it not completely flawed or anywhere near it, or at least it wasn’t at its last outing. Also what’s the alternative, no diagnosis? Having no name for what the patient is suffering from (most diagnoses include a requirement that the problem is causing significant disruption to the person’s life) and then offering the hodgepodge of integrative interventions just leads to something unsystematic and unaccountable6. “Diagnoses fail to predict the effectiveness of particular treatments”. This is untrue, the inclusion criteria for many studies involve diagnosis and many of these show that both biological and psychological interventions are effective for many conditions7. “But diagnosis and the language of biological illness obscure the causal role of factors such as abuse, poverty and social deprivation.” Locating the cause in biology does this but diagnosis itself does not. Many studies on mood, personality and psychotic disorders, some of them seminal e.g. Brown and Harris, use diagnosis and identify abuse, poverty and social deprivation as causal factors. Also the two examples you cite PTSD & grief have causal life events as a prerequisite in their definition/diagnosis. This matter is complicated further by the fact you mention (accurately) in your 19th Jan post that the things that have happened to people can give rise to stress which in turn affects the way the brain works.

8. Stigma, discrimination and social exclusion are genuine issues associated with diagnosis but they’re also associated with lack of social success and public failure or struggle and maybe this says something about how compassionate we are towards those in difficulty and is a bigger problem. Diagnosis can also reduce stigma and discrimination, as it has done in the recognition of PTSD among war veterans.9. To suggest that formulation does not include value judgements about clients or patients that also have the potential to be stigmatising is nonsense. For example, attachment difficulties, problems with emotional regulation, narcissism, unstable sense of self, impulsiveness, histrionic behaviour, dysfunctional beliefs etc. It can be instructive to consider if someone was told that any of these issues were leading to their difficulties in coping or functioning whether they might also feel labelled and criticised10. Diagnosis sometimes allows people access to treatment, helps them understand their difficulties and indicates which treatments should not be used. Without doubt, the fact that a diagnosis of a serious mental illness sometimes affects peoples’ liberty in terms of driving, insurance, emigration, etc needs more careful consideration especially since up to 20% of people with psychosis experience one episode only. This should and must be tackled under discrimination laws but not all diagnoses are for such conditions.11. The use of formulation and diagnosis together can be a helpful, but not always. It can be helpful in distinguishing presentations that look like and overlap with certain diagnoses but aren’t that particular condition. But I worry that it might be used to distinguish problems that don’t have clear antecedents from those that do and this could be problematic for a number of reasons e.g. subtle forms of adversity, recurrences of a condition which as we know don’t necessarily need to have a trigger

In relation to the above comment. I agree that diagnosis can be helpful in some instances. However, the impression that I get from having read Professor Kinderman's thoughts on diagnosis, aren't that it should be abolished, rather, that diagnoses be made less loosely.

A large majority of mental disorders are anxiety-related, as a result of social and environmental factors. Causalities such as: bullying, abuse, rejection, failiure, and trauma.

It's a natural human response to develop coping-mechanisms, and to experience anxiety and/or depression, as a result of emotionally distressing experiences.

If I am right-in-thinking, Professor Kinderman, is pointing out that rather than label every possible coping-mechanism, and anxiety (as an individual disorder), it would make more sense to seek-out the root-cause of the anxiety, and depression, in order to understand and address individual fears. By means of changing perception, and mindset.

Medication does not reach the root-cause in the majority of mental-illnesses, rather it desensitises, and distracts individuals from their anxieties. It is also not uncommon to suffer additional problems, as a result of side-effects.

As for PTST, this is an understandable human response to trauma. Why should it be necessary to label a person who has experienced trauma with a disorder? Cannot simply the effects be understood and treated, without labelling?

Of course there are situations in which diagnosis is helpful. Noteably, when a person is suffering from depression, or anxiety, to the point it affects him, or her, occupationally. To simply avoid the work place, is in-excusable without legitimate reasoning.

If a problem is left untreated, and the cause is never addressed, individuals may be deemed as suffering from 'chronic depression', or long-term illness. The implications of this, are more serious than an isolated bout of depression.

Such a person may be considered susceptible to low-moods thereafter.

I hope Professor Kinderman is able to make a difference, and that his views on mental health will be taken-on board. He speaks perfect sense.

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